Provider Demographics
NPI:1891763652
Name:URSIC, CAESAR MARCELO (MD)
Entity Type:Individual
Prefix:
First Name:CAESAR
Middle Name:MARCELO
Last Name:URSIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:
Practice Address - Street 1:1631 HOSPITAL DR
Practice Address - Street 2:SUITE 240
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-954-8728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0735208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
QMYPR0071514OtherMOLINA
10024240OtherLOVELACE
NM32428766Medicaid
742912OtherCCN
2587220OtherUHC
202004080OtherPRESBYTERIAN HEALTH PLANS
NMNM009X45OtherBCBS NM
NMNM009X45OtherBCBS NM
NMGR0084565Medicare ID - Type Unspecified
NM349604604Medicare PIN